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It Is Complex: Predicting Gastroschisis Outcomes Using Prenatal Imaging
Sarah G Fisher1, Cassandra M Anderson1, Nicole P Steinhardt2
1Section of Pediatric Surgery, Riley Hospital for Children, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
Insights
Prenatal ultrasound can predict complex gastroschisis, a condition requiring longer feeding times and hospital stays. Absence of specific ultrasound markers suggests uncomplicated gastroschisis, aiding in early outcome prediction.
Area of Science:
- Pediatric Surgery
- Fetal Medicine
- Neonatology
Background:
- Gastroschisis affects 1 in 2000 births, with outcomes influenced by intestinal complications and feeding timelines.
- Prenatal imaging advancements offer improved insight into postnatal outcomes for gastroschisis.
- Survival rates are linked to managing intestinal issues and the time to initiate feeding.
Purpose of the Study:
- To analyze gastroschisis patient data from a single children's hospital in the modern era.
- To utilize prenatal ultrasound (US) findings to develop novel prognostic indicators for gastroschisis.
- To identify prenatal US markers that predict the severity of gastroschisis at birth.
Main Methods:
- Retrospective review of 134 gastroschisis patients (2010-2018) at a quaternary-care children's hospital.
- Evaluation of second and third-trimester prenatal US for amniotic fluid levels, external bowel characteristics, and bowel wall edema.
- Comparison of complex gastroschisis (atresia/perforation) with uncomplicated cases using statistical analyses (chi-square, univariate, multivariable).
Main Results:
- Complex gastroschisis patients required significantly longer median days for feeding initiation (44 vs. 10 days) and full feeding (80 vs. 23 days).
- Third-trimester prenatal US showed polyhydramnios in 23.5% of complex cases versus 4.3% of uncomplicated cases (P=0.018).
- Key US predictors for complex gastroschisis included significant polyhydramnios, increased external bowel, bowel edema, and bowel dilation on third-trimester scans.
Conclusions:
- Polyhydramnios on third-trimester prenatal ultrasound is a significant predictor of complex gastroschisis.
- Absence of specific prenatal US markers suggests uncomplicated gastroschisis, aiding in outcome prediction.
- Complex gastroschisis is associated with prolonged time to feeds and extended hospital stays.
Background:
Gastroschisis occurs in one of 2000 births with survival rates partially contingent on intestinal complications and time to establishing feeding. Enhancements in prenatal imaging have given better insight into postnatal outcomes. The goal of this study was to examine the gastroschisis patient population at a single children's hospital in the modern era and to use prenatal ultrasound (US) to develop new prenatal prognostic indicators.
Methods:
We performed a retrospective review of gastroschisis patients at a quaternary-care referral children's hospital from 2010 through 2018. We recorded demographics, prenatal data and imaging, early postnatal data, operative data, and patient outcomes. We compared patients within our cohort born with complex gastroschisis (bowel atresia/perforation) to uncomplicated gastroschisis patients. Second trimester and third trimester prenatal US were evaluated for changes in amniotic fluid level, amount of external bowel, bowel dilatation, and bowel wall edema to identify prognostic indicators of the status of the bowel at birth. For categorical variables, chi-square tests were used to assess for significance. Univariate and multivariable analyses were used to assess significance between categorical and continuous variables using medians and interquartile ranges or means.
Results:
A total of 134 patients were included in the study: complex (n = 24), uncomplicated (n = 110). Compared with uncomplicated gastroschisis, complex patients required longer median days to feeding initiation (44 versus 10; P < 0.001), full feeding (80 versus 23; P < 0.001), length of stay (83 versus 33; P < 0.001), and total parenteral nutrition at discharge (P = 0.004). Full US data were available on 81% of patients, and partial data were identified on 19%. Prenatal US analysis showed significantly more complex patients had polyhydramnios on third trimester US (23.5%-4.3%; P = 0.018). US analysis showed these additional factors to be most associated with complex gastroschisis: large amount of external bowel on third trimester US, increase in bowel edema on third trimester US, and increase in external bowel dilation on third trimester US. Multivariable logistic regression analyses revealed amniotic fluid on third trimester US to be the most significant predictor of complex gastroschisis (P = 0.01). Polyhydramnios in combination with two-thirds of the other US factors had both sensitivity and positive predictive value for predicting complex gastroschisis of 75%. Patients with two or less of these positive US factors had high specificity (96.8%) and negative predictive value (87.5%), suggesting uncomplicated disease. There were no differences in perioperative or long-term complications in the complex group when compared with the group with uncomplicated gastroschisis.
Conclusions:
Polyhydramnios on third trimester prenatal US on babies with gastroschisis can predict complex gastroschisis at birth, whereas the absence of markers on prenatal US can suggest uncomplicated disease. Complex gastroschisis is associated with increased time to feeds and length of stay.
